The impact of CHADS2 score on late stroke after the Cox maze procedure

Abstract

Objective The Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society jointly recommend indefinite warfarin anticoagulation in patients with CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke) score of at least 2 who have undergone ablation for atrial fibrillation. This study determined the impact of CHADS2 score on risk of late stroke or transient ischemic attack after the performance of a surgical Cox maze procedure. Methods A retrospective review of 433 patients who underwent a Cox maze procedure at our institution was conducted. Three months after surgery, warfarin was discontinued regardless of CHADS2 score if the patient showed no evidence of atrial fibrillation, was off antiarrhythmic medications, and had no other indication for anticoagulation. A follow-up questionnaire was used to determine whether any neurologic event had occurred since surgery. Results Follow-up was obtained for 90% of the study group (389/433) at a mean of 6.6 ± 5.0 years. Among these patients, 32% (125/389) had a CHADS2 score of at least 2, of whom only 40% (51/125) remained on long-term warfarin after surgery. Six patients had late neurologic events (annualized risk of 0.2%). Neither CHADS2 score nor warfarin anticoagulation was significantly associated with the occurrence of late neurologic events. Among the individual CHADS2 criteria, both diabetes mellitus and previous stroke or transient ischemic attack were predictive of late neurologic events. Conclusions The risk of stroke or transient ischemic attack in patients after a surgical Cox maze procedure was low and not associated with CHADS2 score or warfarin use. Given the known risks of warfarin, we recommend discontinuation of anticoagulation 3 months after the procedure if the patient has no evidence of atrial fibrillation, has discontinued antiarrhythmic medications, and is without any other indication for systemic anticoagulation.

Predictors and Risk of Pacemaker Implantation After the Cox-Maze IV Procedure

“…This has simplified the procedure, making it faster, safer, and easier for surgeons to perform without diminishing procedural efficacy with respect to freedom from both AF and stroke [4, 6, 11]. These technical improvements, coupled with the increasing numbers of AF patients undergoing cardiac operations, have resulted in more patients being offered surgical ablation either as a lone procedure or concomitantly with other open heart procedures [9].…”

“…Although there remains ongoing debate about the efficacy of rate-control strategies, the restoration of sinus rhythm has particular benefits related to reducing the risk of thromboembolism and stroke, the most serious complications of AF [2–4]. Although most AF patients are initially treated with antiarrhythmic drugs, the limited efficacy and significant side effects of these medications have constrained their usage while simultaneously increasing the number of catheter-based and surgical-based procedures offered as a treatment for AF patients.…”

Minimally invasive surgery for atrial fibrillation

“…With regard to stroke prevention, our practice is to manage the left atrial appendage in all patients by either excision or exclusion, and to discontinue anticoagulation at three months post-ablation in patients who are in normal sinus rhythm on prolonged cardiac monitoring and have no evidence of left atrial stasis on echocardiogram, regardless of the CHADS2 score. We have demonstrated a very low stroke rate of 0.2% per year in long-term follow-up with this approach (21).…”

Surgery for Atrial Fibrillation

“…If after a 3 month blanking period the patient has no ATAs off antiarrhythmic medications on prolonged monitoring (at least a 24 hour Holter), and demonstrates no atrial stasis on echocardiography, we recommend the discontinuation of warfarin. 19 Using this approach, we have had a very low stroke risk after the CM procedure even in patients with high CHADS 2 scores.…”